Ca Request And Authorization For Disclosure Of Health Information Page 2
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4□ Other (must list names and relationship to member): ___________________________
________________________________________________________________________
(5)
I understand that I may revoke this authorization at any time by sending a written notice
of my revocation to the address listed below. I understand that revocation of this
authorization will not affect any action your dental plan or it’s subsidiaries, affiliates,
business associates, etc. took in reliance on this authorization before it received my
written notice of revocation. I also understand that without my written authorization, my
dental plan may not use or disclose my health information for any reason except those
described in Notice of Privacy Policies and Practices. Unless otherwise revoked, this
authorization will expire on the following date.
This authorization expires on ____/____/______.
[Insert applicable date. If no
expiration date is stated, this authorization will be deemed to expire one year from the
date of execution.]
I understand that authorizing the disclosure of this health information is voluntary, and is
not a condition of enrollment in this health plan’s eligibility for benefits, or payment of
claims.
I understand that, if the persons or organizations I authorize to receive and/or use the
protected health information described above are not health plans, covered health care
providers or health care clearinghouses subject to federal health information privacy
laws, they may further disclose the protected health information and it may no longer be
protected by federal health information privacy laws.
I release my dental plan, its affiliated companies, employees, officers and business
associates from legal liability for any recipient’s use or disclosure of information released
by my dental plan in reliance on this authorization.
______________________________________________________
____________
Signed (member or personal representative)
Date
_______________________________________________________
Printed name of signature above (member’s personal representative)
_______________________________________________________
Description of the representative’s authority to act for the member
You are entitled to a copy of this authorization after you sign it. Any revocation or change
to this authorization, or any questions regarding its legal effect, should be addressed to:
Dental Customer Service
P.O. Box 69420
Harrisburg, PA 17106-9420
If you have any questions, please call Dental Customer Service at the telephone number located
on the back of your identification card. You may fax this form to 1-866-335-3969 or return the
form to the address listed above.
CA Request and Authorization for Disclosure of Health Information-3/21/14
9/27/16
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Parent category: Medical